Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.

Case Study: A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform breast self-examination often, she thinks that this lump is new. She denies nipple discharge or breast pain, although the lump is mildly tender on palpation. She has never noticed any breast masses previously and has never had a mammogram. She has no personal or family history of breast disease. She takes oral contraceptive pills (OCPs) regularly, but no other medications. She does not smoke cigarettes or drink alcohol Links to an external site.. She has never been pregnant. On examination, she is a well-appearing, somewhat anxious, and thin woman. Her vital signs are within normal limits. On breast examination, in the lower outer quadrant of the right breast, there is a 2-cm, firm, well-circumscribed, freely mobile mass without overlying erythema that is mildly tender to palpation. There is no skin dimpling, retraction, or nipple discharge. While no other discrete breast masses are palpable, the bilateral breast tissue is noted to be firm and glandular throughout. There is no evidence of axillary, supraclavicular, or cervical lymphadenopathy. The remainder of her physical examination is unremarkable.

 

I have seen this so many times in my career.  Family members even become clued in that their family member is probably having a urinary tract infection because of their confusion.

General Question:  How could an infection, such as a urinary tract infection (UTI) lead to confusion in an older adult?  What physiological changes might explain this? 

Assignment Objectives:

For this assignment, you will appraise a clinical practice guideline (CPG).  The purpose of this assignment is to acquaint you with a clinical practice guideline as well as the appraisal process to determine the feasibility of the CPG.

Assignment Instructions: 

Read/Review the clinical practice guideline provided below:

• Practice Guidelines for Psychiatric Evaluation of Adults Download Practice Guidelines for Psychiatric Evaluation of AdultsOpen this document with ReadSpeaker docReader This guideline may also be helpful to you as you move through the program as you will have many opportunities to evaluate adults with psychiatric needs.  

You will appraise the clinical practice guideline using the AGREE II Tool Download AGREE II Tool for evaluating Clinical Practice Guidelines.  You must download the document to your computer, save it, and then open the document.  You should then be able to type in the comment section for each of the items to provide your responses.  You will not be able to type in the document if you just download it here without saving it first.  Here is the user’s guide for the AGREE II Tool Download user’s guide for the AGREE II Tool  Beginning on page 11 of the guide, you will find a detailed explanation of the purpose for each section of the tool, an overview of how to score that section, as well as where to locate this information in your CPG.  

A rationale and “answer” must be provided for each item in the comment section so that we can “see” how you formulated your response to that section.

How to Read the Guideline to Complete the Critique Assignment

The guideline that you are being asked to review contains many sections within the overall document.  Pages 1-3 and 145-148 decribe the process for developing the entire document.  Pages 3-7 provide a list of key recommendations found within the individual sections of the document for immediate access. This is followed by the references for the document (a complete reference list is on pages 150-162).  Beginning on page 9, you will find an indepth discussion of each of the different components of the guideline.  Each section is laid out in the same manner:  

• Guideline Statements:  This is where you will find a summary of the recommendations made based on the review of hte literature
• Rationale:  This section provides a rationale for the development of that specific guideline as well as a discussion of the strength of the evidence identified for this guideline.  
• Potential Benefits and Harms:  This section provides a discussion of the benefits and harms associated with using or not using these recommendations.  There may also be a discussion of the need for future research in this area.
• Implementation:  This section provides a discussion of how to use these recommendations in practice.  Other resources that can be used to enhace the assessment of this section are also provided.  Barriers to implementation of the guideline are also discussed.

Typically, a clinical practice guideline will be one document that contains recommendations for practice for one particular subject.  Since the psychiatric evaluation contains many components, the guideline you are asked to review contains several “mini” guidelines which make up the overall guideline for the “Psychiatric Evaluation of Adults.”  You will use the information on pages 1-9 and 145-148 to answer the majority of the critique items in Domains 1-3 of the AGREE II tool. 

To answer items 11 and 12 in Domain 3 and the items in Domains 4-5, you will choose ONE of the guidelines to follow through the Guidelines and Implementation section, the Review of Available Evidence section. and the Quality Measurement Considerations section of the CPG.  For example, if you choose to do an indepth review of Guideline III:  Assessment of Suicide Risk, you will look on pages 18-23, 57-65, and 139-140 to answer the specific questions about that guideline.